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ORTHOPEDIC    SURGERY. 


^ASES 


ORTHOPEDIC    SUEaERY.' 


BEAD  BEFOBE 


%\t  Itassatfeis^tts  iltljital  Somts, 


ANNUAL  MEETING,  JUNE  3,   1868 


By  BUCKMINSTER  'BROWN,  M.D., 

Fellow  of  the  Society,  Member  of  the  Boston  Society  for  Medical  Improvement,  etc.  etc. 


WnH  PHOTOGRAPHIC  ILLUSTRATIONS  OF  THE  CASES 
PRESENTED. 


BOSTON: 

DAVID  CLAPP  &  SON,  334  WASHINGTON  ST. 

1868. 


I  HI 


ORTHOPEDIC    SURGERY. 


Members  of  the  Profession,  both  those  residing  in '  the 
city  and  those  coming  from  a  distance,  are  frequently  re- 
minding me  that  cases  showing  the  results  which  can  now 
be  attained  by  combined  operative  and  mechanical  surgery, 
in  the  treatment  of  deformities,  possess  a  great  interest  for 
the  general  practitioner.  Acting  upon  these  suggestions,  it 
is  proposed  at  this  time  to  state,  in  few  words,  the  history 
of  several  cases,  most  of  which  have  recently  come  under 
my  observation,  and  are  brought  forward  as  examples  of 
some  of  the  various  classes  into  which  this  branch  of  sur- 
gery is  divided.  The  better  to  elucidate  the  subject,  casts 
or  photographs  will  be  shown,  before  and  after  treatment ; 
and,  in  two  or  three  instances,  I  am  enabled  to  present  the 
patient  to  the  Society  for  examination. 


Case  I.     Casts  Nos.  1  and  2.     Photographs  1  and  2. 

Talipes. — The  first  case  to  which  I  will  draw  attention  is 
the  one  from  which  this  cast  and  this  photograph  were  taken. 
(See  Case  I.,  Plate  I.,  figui-e  1.)     A  boy  born  with  such  a 


6  CASES  IN  OETHOPEDIC   SUEGERY. 

distortion  of  the  leg  and  foot  that  the  great  toe  was  turned  up 
against  the  side  of  the  knee,  and,  when  the  child  was  awake, 
was  in  close  contact  with  the  internal  condyle  of  the  femur. 
The  tibialis  anticus  and  posticus  muscles  were  strongly  con- 
tracted— structurally  shortened.  The  treatment  consisted  in 
the  division  of  the  tendons  of  these  muscles,  and  in  the  use 
of  a  variety  of  apparatus,  employing  sometimes  the  spring 
and  sometimes  the  screw  power.  By  these  means  the  leg 
and  foot  were  gradually  brought  into  a  normal  position. 
By  the  time,  however,  this  result  was  somewhat  more  than 
half  accomplished,  the  tendons,  growing  more  rapidly  than 
the  bones,  had  united,  and  again  presented  an  obstacle  to 
further  improvement.  These  were  re-divided,  and,  in  about 
six  months,  the  result  was  as  shown  in  the  second  cast.  (See 
Case  I.,  Plate  I.,  figure  2.)  The  second  photograph  gives 
a  correct  idea  of  the  foot  when  it  was  nearly  straight. 
When  I  last  saw  the  child,  he  walked  on  the  sole  of  his  foot. 


Case  II.     Casts  Nos.  1,  2,  3,  4. 

This  is  a  case  of  paralytic  calcaneo-valgus,  the  result  of 
spina  bifida.  (See  Case  II.,  Plate  I.,  figures  3  and  5.)  The 
patient  is  a  girl  eleven  years  old.  It  is  evident  that  in  the 
left  foot  the  articular  facet  of  the  astragalus,  instead  of 
being  applied  against  the  internal  malleolus,  does  not  enter 
into  the  composition  of  the  ankle-joint,  but,  with  its  rounded 
internal  face,  and  with  the  scaphoid,  forms  the  projection  on 
the  inside  of  the  foot.    It  will  be  seen  that  the  front  part 


CASES   IN   ORTHOPEDIC   SURGERY.  7 

of  the  foot  13  higher  than  the  heel,  therefore  it  is  calcaneo- 
valgus;  yet,  in  reality,  from  the  displacement  of  tlie  cal- 
caneum,  the  origin  and  insertion  of  the  gastrocnemius  are 
approximated.  Thus  is  presented  the  somewhat  anomalous 
state  of  the  parts  in  which,  although  treating  a  case  of  cal- 
caneus, instead  of  desiring  to  shorten  the  tendo-Achillis,  we 
are  obliged  to  increase  its  length  before  the  foot  can  be  re- 
placed. The  tendons  divided  in  the  left  foot  were  the  three 
peronei,  the  extensor  longus-communis,  extensor  pollicis- 
pedis,  the  tibialis  anticus  and  the  tendo-Achillis.  The  same 
tendons  were  divided  in  the  right  foot,  with  the  exception  of 
the  tibialis  anticus  and  the  tendo-Achillis.  I  here  present 
the  models  of  the  feet,  as  they  were  before  treatment,  and 
four  months  after  the  commencement  of  treatment.  (See 
Case  II.,  Plate  I.,  figures  3,  4,  5,  6.)  The  child  is  able  to 
walk  on  the  soles  of  the  feet. 


Case  III.     Casts  1  and  2.     (Patient  present.) 

There  are  but  few  cases  in  which  the  patients  are  so  situated 
as  to  appear  on  such  an  occasion  as  this.  Either  they  live  at 
too  great  a  distance,  or  they  dislike  to  be  presented.  This 
boy,  however,  willingly  comes  forward.  He  well  illustrates 
the  legitimate  results  of  the  combination  of  operative  and  me- 
chanical surgery.  He  is  nine  years  of  age.  He  had  con- 
genital varus  of  the  right  foot.  Continued  use  of  the  foot 
had  converted  it  into  what  has  been  termed  varo-dorsalis. 
The  foot  had  been  operated  upon  some  years  previous  to 


8  CASES  IN  ORTHOPEDIC  SURGERY. 

coming  under  my  care.  I  divided  the  tibialis  anticus,  plantar 
fascia  and  tendo-Achillis.  (See  Case  III.,  Plate  II.,  figures 
1  and  2.) 


Case  IV.     Cast  No.  1,  and  Patient. 

-  I  have  here  a  caist  of  one  foot  from  a  case  of  double  tali- 
pes varus.  The  feet  were  alike.  (The  patient  will  stand 
upon  the  table,  or  walk  around,  that  gentlemen  who  wish 
may  examine  her  feet.)  (See  Case  IV.,  Plate  IL,  figures  3 
and  4.) 


Case  V.     Casts  Nos.  1  and  2,  and  Patient. 

TJiis  cast,  (see  Case  V.,  Plate  11.,  figure  5)  speaks  for 
itself.  The  child  is  three  and  a  half  years  old.  She  had 
paralytic  varus.  The  tendo-Achillis,  tibialis  anticus  and 
posticus,  and  extensor  longus  pollicis  pedis  were  rigidly  con- 
tracted. These  tendons  were  divided  in  February,  1868. 
In  twenty  days  after  the  operation,  the  paralyzed  muscles, 
no  longer  kept  fully  extended  by  their  contracted  antagonists, 
completely  recovered  their  power,  and  the  child  was  able  to 
flex  and  abduct  the  foot.  A  cure  was  effected  in  two  months. 
(See  Case  Y.,  Plate  II.,  figure  6.)  The  child  is  now  under 
treatment  for  contracted  knee,  arising  from  the  same  cause. 
The  biceps  flexor  cruris  has  been  recently  divided. 

Paralysis  is  rarely  the  cause  of  congenital  varus.  Non-con- 
genital Varusj  however,  frequently  arises  from  paralysis  of  a 
single  muscle  or  of  a  set  of  muscles.    On  the  other  hand,  the 


CASES  IN  ORTHOPEDIC  SURGERY.  9 

etiology  of  both  congenital  and  non-congenital  valgus  may  so 
constantly  be  traced  to  debility  of  muscles  and  ligaments — 
amounting,  in  the  majority  of  cases,  to  complete  paralysis — 
as  almost  to  form  the  rule  in  this  class  of  cases.  The  return 
of  power  to  the  paralyzed  muscles  I  have  frequently  observed 
after  division  of  the  healthy  muscles,  -which  are  structurally 
shortened  in  consequence  of  the  normal  balance  of  power 
having  been  destroyed. 


Case  VI.     Casts  Nos.  1  and  2. 

Within  a  year  or  two,  much  has  been  said  and  written  in 
regard  to  the  cure  of  talipes  without  tenotomy.  This  case 
may  be  cited  (one  among  several  that  could  be  referred  to) 
as  a  fair  instance  of  the  result  of  such  attempts.  (See  Case 
VI.,  Plate  III.,  figure  1.)  The  child  from  whom  the  cast 
was  taken  was  born  with  double  talipes  varus.  A  few  days 
after  birth  the  treatment  by  apparatus  was  commenced,  and 
was  continued  two  years.  For  three  months  the  patient 
was  visited  daily  by  the  attending  surgeon.  The  result, 
after  two  years,  was  a  failure,  as  is  shown  in  the  first  cast, 
taken  when  he  came  under  my  treatment.  The  second  cast 
was  taken  three  months  afterwards.  (See  Case  VI.,  Plate 
in.,  figure  2.) 


Case  VII.     Casts  Nos.  1  and  2. 

The  cast  I  have  in  my  hand  (see  Case  VII.,  Plate  HI.,  fig- 
ure 3),  represents  a  case  of  varus,  interesting  from  the  fact 

2 


10  CASES  IN  ORTHOPEDIC  SURGERY. 

that  a  somewhat  similar  attempt  to  the  preceding  had  been 
made  to  cure  the  foot.  It  has  been  said  the  hand  of  the 
mother  or  nurse  is  in  truth  the  best  apparatus.  In  this  case 
the  mother,  instructed  by  her  physician,  had  devoted  herself 
to  the  task.  She  had  held  the  foot  in  her  hands,  on  the 
stretch  towards  a  straight  line,  four  hours  a  day  for  three 
months.  Flexion  was  impossible  from  any  force  that  could 
be  applied  to  it.  That  her  labor  was  thrown  away  is  shown 
in  this  first  cast  taken  when  the  patient  was  brought  to 
Boston.  This  second  cast  shows  the  foot  after  tenotomy 
and  subsequent  treatment.    (See  Case  VII.,  Plate  III.,  fig.  4.) 


Case  VIH.    Casts  Nos.  1  and  2. 

I  have  cited  cases  showing  the  nugatory  effects  of  pro- 
tracted mechanical  treatment  without  operation.  Here  are 
a  couple  of  casts,  not  remarkable  in  themselves,  but  in- 
teresting as  examples  of  numerous  cases  exhibiting  the 
same  or  worse  results  from  the  opposite  mode  of  treatment, 
viz. : — too  much  surgery  without  appropriate  after-treatment. 
The  lad,  from  whom  this  model  was  taken,  had  been  operated 
upon  six  times  by  a  distinguished  New  York  surgeon.  The 
tendo-Achillis  was  divided  three  times.  After  five  years 
treatment  the  foot  was  as  malformed  as  at  first.  (See  Case 
VIIL,  Plate  ni.,  figure  5.)  The  second  model  was  taken 
after  the  boy  had  been  in  Boston  three  months.  (See  Case 
Yni.,  Plate  III.,  figure  6.) 


CASES  m  ORTHOPEDIC  SUEGERY.  11 

Case  IX.     Casts  Nos.  1  and  2. 

These  casts  furnish  another  instance  of  the  fact  just  al- 
luded to.  The  boy  had  double  varus,  third  degree.  He 
had  been  operated  upon  ten  or  twelve  times  ,•  and  had  like- 
wise been  under  treatment  five  years  by  surgeons  in  New 
York  and  at  the  West,  with  the  disastrous  result  seen  in  the 
first  cast.  (See  Case  IX.,  Plate  lY.,  figure  1.)  The  second 
cast  shows  the  feet  (they  were  alike)  when  he  left  Boston. 
(See  Case  IX.,  Plate  lY.,  figure  2.) 


Cases  X.  and  XI.    Casts. 

In  order  to  make  the  series  more  complete,  there  are  on 
the  table,  one  sample  of  talipes  equinus  before  and  after 
treatment  (See  Case  X.,  Plate  lY.,  figures  3  and  4) ;  also 
casts  of  a  case  of  varus,  treated  several  years  since,  intro- 
duced simply  to  show  that  the  growth  and  strength  of  the  mem- 
bers are  not  diminished  by  somewhat  extensive  tenotomy. 
The  case  was  one  of  extreme  double  varus.  The  tendo-Achil- 
lis  in  each  foot  was  twice  divided,  also  the  tibialis  posticus 
and  flexor  longus  pollicis  pedis.  The  boy  was  treated  and 
cured,  when  eight  years  of  age.  The  second  cast  was  taken 
twelve  years  afterwards.  (See  Case  IL,  Plate  Y.,  figures 
1  and  2.)  These  years  the  lad  had  passed  chiefly  at  sea, 
doing  duty  as  a  sailor.  He  has  since  become  master  of  a 
vessel,  and  states  that  he  has  never  experienced  the  slightest 
inconvenience  from  his  feet. 


12  CASES  m  ORTHOPEDIC  SURGERY. 

Case  Xn.     Casts  Nos.  1  and  2. 

This  is  an  example  of  a  case  of  genu-varum  or  bow-legs. 
(See  Case  XII.,  Plate  V.,  figure  3.)  Both  legs  were  simi- 
larly afiected.  It  is  curious  to  notice,  that,  although  the  legs 
were  tightly  strapped  on  the  convex  side  for  months,  yet 
the  healthy  growth  and  development  were  not  impeded, 
as  is  well  shown  in  the  second  cast.  (See  Case  XII., 
Plate  Y.,  figure  4.)  This  will  be  found  to  be  the  rule  in  all 
cases  where  the  apparatus  is  so  applied  as  not  materially  to 
interfere  with  the  circulation. 


Case  Xni.     Photographs  Nos.  1  and  2. 

This  photograph  (see  Case  XIII.,  Plate  YL,  figure  1)  re- 
presents the  legs  of  a  little  girl  as  they  were  when  she  came 
under  treatment.  It  was  a  bad  case  of  genu-valgum  of  the 
right  leg,  and  genu-varum  of  the  left.  The  result,  as  shown 
in  the  accompanying  photograph,  was  attained  by  apparatus 
without  tenotomy.     (See  Case  XIII.,  Plate  YI.,  figure  2.) 


Case  XIY.    Photographs  Nos.  1  and  2. 

These  photographs  were  taken  from  another  case,  of  a 
similar  nature  to  the  preceding,  before  and  after  treatment. 
In  this  case,  also,  no  operation  was  required.  The  distor- 
tion, in  both  instances,  was  caused  by  malformation  of  the 
joints,  uncomplicated  by  muscular  contraction.* 

*  The  photographs  of  Case  XIV.  are  not  copied  for  publication,  as  the  case 
resembles  that  represented  on  Plate  VI. 


CASES  IN  OETHOPEDIC   SURGERY.  13 

Lateral  Curvature  of  the  Spine,  or,  according  to  the 
latest  and  best  authority,*  "  Rotato-Lateral  Curvature,"  in 
its  advanced  stages,  is  one  of  the  most  discouraging  affec- 
tions with  which  we  have  to  deal.  Much,  however,  can  be 
accomplished  by  patience  and  perseverance.  In  spinal  cur- 
vature, as  in  most  other  cases  pertaining  to  this  branch  of 
surgery,  frequent  variation  of  the  treatment,  and,  where  ap- 
paratus is  employed,  a  frequent  change  in  the  appliances,  is 
required.t  They  should  be  modified  according  to  the  exi- 
gencies of  the  case,  adapting  the  means  employed  to  the 
changes  in  the  form  as  the  cure  proceeds.  It  may  be  interest- 
ing to  mention  an  extreme  case  of  this  complaint  which  has 
recently  come  under  my  observation. 


Case  XV. 

Miss ,  aged  3 1 .    Has  had  curvature  of  the  spine  from 

childhood.  Her  body,  from  neck  to  hips,  has  gradually 
shortened.  For  this  there  is  a  partial  compensation  in  the 
greatly  increased  antero-posterior  diameter  of  the  chest. 
On  examination,  I  found  the  crest  of  the  ilium,  on  the  left 
side,  to  be  two  inches  from  the  axilla.  On  the  right,  the  dis- 
tance is  two  and  three-fourths  inches.  In  fact  these  bones 
are  lodged  directly  beneath  the  shoulders.     The  os  pubis  is 

*  On  Spinal  "Weakness  and  Spinal  Curvature ;  its  early  Recognition  and  Treat- 
ment.   By  W.  J,  Little,  M.D.    London,  1868. 

t  This  rale  applies,  with  especial  force,  to  talipes.  In  every  species  of  club- 
foot, excepting  where  the  twist  is  very  slight,  from  two  to  six,  or  even  more 
yarieties  of  apparatus  are  often  required  to  make  a  perfect  foot. 


14  CASES  IN  OETHOPEDIC  SURGERY. 

three  and  one-half  inches  from  the  sternum.  Relief,  by  an 
accurately  adjusted  support,  was  the  only  treatment  admissi- 
ble.    Such  extraordinary  cases  are  rarely  met  with. 


Case  XYI.    Photographs  1  and  2. 

Here  is  a  photograph  of  the  back  of  a  boy  from  Law- 
rence, Kanzas.  (See  Case  XYI.,  Plate  VII.,  figure  1.)  He 
had  severe  lateral  curvature.  The  left  hip  was  very  promi- 
nent. The  trunk,  above  the  hips,  was  thrown  so  far  to  the 
right,  that  the  centre  of  the  occiput  was  on  a  line  with  the 
*  right  leg ;  consequently,  in  standing,  the  weight  of  the 
body  was  sustained  by  this  leg.  The  right  scapula  and  ribs 
projected,  and  the  left  scapula  sank  into  the  hollow  formed 
by  the  curve.  This  unequal  distribution  of  the  weight  of 
the  body  had  produced  an  inward  inclination  of  the  left 
knee.  The  second  photograph  (See  Case  XVI.,  Plate  VH., 
figure  2)  shows  the  state  of  the  spine  some  months  since. 
It  is  now  still  further  improved.  The  left  shoulder,  formerly 
much  below  the  level  of  the  right,  is  now  the  higher.  This 
will  rectify  itself.     The  knee  was  cured  by  proper  apparatus. 


Caries  op  the  Cervical  Vertebra,  compared  with  the 
same  afifection  as  it  attacks  other  regions  of  the  spinal  col- 
umn, is  a  rare  disease.  Some  years  since  I  published  an 
account  of  a  case  of  caries  of  the  upper  bones  of  the  neck, 
remarkable  in  many  points  of  view,  which  terminated  fatal- 
ly.   The  atlas,  axis  and  base  of  the  cranium  were  eroded, 


CASES  IN  ORTHOPEDIC  SURGERY.  15 

and  death  was  caused  by  fracture  of  the  odontoid  process. 
The  pathological  appearances  were  minutely  described. 
About  the  same  time  two  or  three  similar  instances  presented 
themselves,  which  were  also  fatal.  Since  then  I  have  treated 
other  cases  of  cervical  caries  which  have  had  a  more  favor- 
able termination.  There  are  present,  to-day,  two  children 
who  have  been  suiFerers  from  this  disease. 


Case  XVH.     (Patient.) 

This  little  girl,  when  I  first  saw  her,  eleven  months  since, 
had  lost  all  voluntary  power  below  her  neck.  She  could 
speak  in  a  whisper.  The  only  muscles  not  paralyzed  were 
those  connected  with  the  eyes  and  mouth.  She  had  been  in 
this  state  some  months.  There  was  swelling  and  prominence 
of  the  lower  cervical  vertebrae.  In  February,  1866,  an  ab- 
scess formed  in  the  neck,  which  continued  discharging,  at  in- 
tervals, for  twelve  months.  She  then  began  to  lose  the  use 
of  her  right  arm  and  leg.  The  paralysis  extended,  involv- 
ing both  arms  and  legs,  with  inability  to  move  the  head. 
For  a  time  the  bladder  was  implicated,  and  the  use  of  a 
catheter  was  required.  She  had  paroxysms  of  severe  pain 
in  the  diseased  bones.  The  child,  as  you  see,  is  now  well 
and  without  deformity.  There  is  scarcely  a  trace  of  the 
affection  remaining. 

I  have  recently  been  informed  that  the  elder  sister  of  this 
patient  died  of  caries  of  the  dorsal  vertebrae,  after  having 
been  paralyzed  three  years. 


I 


16  OASES  IN  ORTHOPEDIC  SURGERY. 

Case  XVIE.     (Patient.) 

This  boy  had  the  same  disease  in  about  the  same  situation. 
The  symptoms,  also,  were  very  nearly  similar,  but  had  been 
of  longer  duration  when  he  came  under  my  observation. 
There  was  complete  paralysis  of  all  the  voluntary  muscles 
below  the  mouth.  He  had  been  unable,  for  months,  to  move 
his  head,  or  to  bend  a  finger  or  a  toe,  or  to  speak  above  a 
whisper.  Severe  pain  was  produced  if  any  attempt  was 
made  to  bend  his  fingers,  wrists,  knees  or  ankles.  The 
joints  were  stiff.  He  had  incontinence  of  urine.  The  res- 
piratory muscles  acted  imperfectly,  and  his  breathing  was 
labored.  His  countenance  expressed  suffering,  and  his  man- 
ner of  rolling  his  eyes,  to  compensate  for  inability  to  move 
his  head,  gave  him  a  very  singular  appearance.  The  paraly- 
sis commenced  about  ten  months  previous  to  his  being  placed 
under  my  care.  The  treatment  consisted,  in  the  first  place, 
of  mechanical  support  to  retain  the  head  in  one  position. 
The  apparatus  was  a  spring  collar,  resting  on  the  clavicles 
and  shoulders,  with  branches  running  down  the  back,  and 
secured  by  a  belt.  Passive  exercise  of  all  the  joints  was 
perseveringly  employed.  Friction,  electro-magnetism,  the 
pyro-phosphate  of  iron,  and  cod  liver  oil  were  important 
adjuncts.  Chloroform  was  given  internally,  to  relieve  pain. 
Power  of  motion  returned  first  to  his  fingers,  and  gradually 
extended,  and  in  three  months  he  began  to  walk. 

In  this  case  it  is  interesting  to  notice  that  the  efforts  of 
nature  to  cure  the  disease  have  exceeded  the  necessity  j  and 
there  has  been  a  great  amount  of  ossific  matter  thrown  out 
around  the  bones,  producing  considerable  deformity  of  the 


CASES  IN  ORTHOPEDIC  SURGEBY.  17 

neck.  An  abscess  formed  and  opened  spontaneously.  The 
boy  is  now  able  to  walk  long  distances,  carrying  bundles 
and  going  on  errands. 


Case  XIX.    (Patient.) 

Hip  Disease. — It  is  impossible,  in  the  brief  time  to  which 
these  papers  are  necessarily  limited,  to  give  more  than  a  very 
imperfect  sketch  of  the  various  diseases,  and  their  effects  in 
deranging  and  distorting  the  human  frame,  which  receive  their 
proper  classification  in  the  branch  of  surgery  we  are  now 
considering.  The  cases  already  brought  forward  are  of  prac- 
tical importance.  Those  last  introduced,  all  "will  acknow- 
ledge, are  eminently  so.  They  are  instructive  instances  of 
the  recuperative  powers  of  nature,  aided  and  guided  by  art  j 
and  teach  us  how  much  these  may  be  relied  upon  even  in 
cases  which  appear  utterly  hopeless.  I  should  be  glad,  if 
time  permitted,  to  draw  your  attention  to  the  several  varie- 
ties of  hip  disease,  referring  to  the  diverse,  and  sometimes 
almost  opposite  modes  of  treatment  appropriate  to  the  dif- 
ferent cases  and  to  the  different  stages  of  the  same  case. 
The  interest  attached  to  these  would  be  increased  if  the  pa- 
tients, showing  in  their  persons  the  results,  could  be  pre- 
sented to  you  as  in  some  of  the  preceding  cases.  My  limits 
allow  me,  at  this  session,  to  bring  forward  one  patient  only. 
He  suffered  from  morbus  coxarius  from  August,  1866,  to 
March,  1867.  When  first  seen  by  me,  in  October,  1866,  he 
could  not  bear  the  slightest  touch  in  the  neighborhood  of  the 

3 


18  CASES  IN  OETHOPEDIC  SURGERY. 

left  hip,  and  had  severe  pain  in  this  joint  and  in  the  knee. 
He  had  frequent  startings  in  the  night,  Avaking  and  scream- 
ing with  pain.  The  patient  was  seen  by  Dr.  J.  Mason  War- 
ren, and  other  surgeons,  during  the  early  months  of  the 
disease.  The  treatment  was  directed,  in  the  first  place,  to 
relieving  the  symptoms  of  acute  action  within  the  joint.  It 
has  been  much  the  fashion  of  late,  for  surgeons  treating  hip 
diseases,  and  those  analogous,  of  the  spine,  to  discard,  as  old 
fashioned,  all  counter-irritants  and  antiphlogistic  remedies. 
Let  me  urge  them  not  to  do  this  in  every  case.  There  are 
certain  varieties  and  phases  of  these  diseases  in  which  there 
are  no  other  means  of  relief  possible.  Mr.  Pott  was  not  so 
utterly  mistaken  as  many  in  these  days  would  have  us  be- 
lieve. There  are  cases  of  disease  of  the  hip  or  spine 
in  which  a  modification  of  his  treatment  is  of  incalculable 
benefit,  and  it  is  only  on  account  of  its  indiscriminate  em- 
ployment in  all  varieties  of  these  complaints,  in  many  of 
which  disappointment  has  attended  its  application,  that  it 
has  fallen  into  discredit. 

In  the  earlier  stages  of  some  species  of  hip  disease,  for 
example,  I  have  too  frequently  seen  the  severe  pain,  the 
extreme  tenderness  of  the  joint — where  the  slightest  jar  is 
agony — the  nocturnal  startings  and  spasms,  and  the  pain  in 
the  knee,  removed,  after  having  existed  for  months,  by  flying 
blisters,  or  by  an  issue,  preceded,  if  the  state  and  history 
of  the  patient  render  it  advisable,  by  slight  local  blood-let- 
ting, to  have  a  doubt  left  in  my  mind  in  regard  to  the  im- 
portance of  these  remedies.  The  relief  is  often  immediate ; 
neither  extension,  nor  rest,  nor  internal  remedies  will  have 


CASES  IN  ORTHOPEDIC  SURGERY.  19 

the  slightest  effect  in  such  cases,  -without  the  aid  of  local 
applications  in  some  one  or  more  of  the  forms  which  experi- 
ence has  taught  us  are  most  beneficial.  Quiet  nights  and 
comfortable  days  were  the  immediate  results  of  this  course 
in  the  case  now  under  consideration.  A  hip-splint  was  ap- 
plied, complete  rest  enjoined,  and  slight  extension  was  used. 
The  apparatus  employed  had  especial  reference  to  the  pre- 
vention of  contraction  or  permanent  displacement  at  the 
joint,  one  of  the  most  frequent  and  unfortunate  sequelae  of 
this  disease,  to  obviate  which  requires  the  exercise  of  the 
utmost  caution.  The  boy  has  been,  for  more  than  a  year,  in 
as  perfect  health  as  you  now  see  him.  There  is  not  the 
slightest  limp.  That  the  hips  are  alike  in  appearance  and 
perfectly  normal  in  action,  will  be  acknowledged  by  those 
who  will  examine  the  patient. 

The  importance  of  attention  to  position  in  hip  complaint 
cannot  be  too  strongly  insisted  upon.  It  may  be  useful,  in 
this  connection,  to  refer  to  a  case  which,  probably,  has  not 
its  counterpart  upon  record.  The  patient  was  a  young  girl, 
thirteen  years  of  age,  who  was  brought  to  me  from  a  distance, 
a  few  years  since.  She  had  suffered,  for  many  months, 
from  doable  hip  disease.  The  complaint  had  gone 
through  its  several  stages,  and  had  terminated  in  anchy- 
losis. From  malposition,  during  the  acute  periods,  both 
thighs  had  become  permanently  fixed  at  right  angles 
with  the  sides  of  the  body,  on  a  line  with  the  axillae,  and 
parallel  with  the  arms  when  stretched  in  such  a  manner  as 
to  afford  the  fullest  expansion  to  the  chest.  In  sitting,  the 
lower  limbs  projected  over  the  sides  of  the  chair.    The  head 


20-  CASES  IN  ORTHOPEDIC  SURGERY. 

of  each  femur  was  joined  to  the  acetabulum  by  a  solid,  bony 
union.  The  case  was  irremediable.  A  greater  misfortune 
can  scarcely  be  imagined.  Double  excision  at  the  hip  joint 
•was  a  procedure  maturely  considered,  but  decided  not  to 
be  advisable  under  the  circumstances. 


Torticollis,  a  less  common  affection  than  any  of  the 
preceding,  has  some  curious  features  which  are  worthy  of 
notice.  Its  causes  are  various.  Frequently  it  arises  from 
contraction,  congenital  or  non-congenital,  of  one  or  both 
branches  of  the  sterno-cleido-mastoideus  muscle,  sometimes 
combined  with  a  similar  affection  of  the  trapezius  or  scaleni. 
Spasm,  permanent  or  intermittent,  the  cicatrices  of  burns, 
and  paralysis,  may  give  rise  to  this  affection.  Other  in- 
stances of  wry  neck  originate  in  rheumatic  inflammation  of 
one  or  all  of  the  muscles  just  named.  I  have  found  the 
trapezius  condensed  into  a  firm,  indurated  tissue,  apparent- 
ly as  unyielding  as  ligament.  I  have  also  seen  very  serious 
distortion  arise  from  rheumatism  attacking  the  inter-verte- 
bral substance  between  two  or  more  of  the  cervical  vertebrae. 
This  disease  will  produce  swelling  and  permanent  thicken- 
ing of  the  ligamentous  tissue  on  one  side,  the  bone,  perhaps, 
being  implicated,  while  the  muscles  are  not  at  all,  or  but 
slightly  involved.  The  peculiar,  characteristic,  rotatory 
twist,  in  these  instances,  is  less  observable  than  in  other  va- 
rieties of  torticollis.  Those  cases  originating  in  the  causes 
first  mentioned  are  generally  incurable  without  division  of  the 


I 


CASES  IN  ORTHOPEDIC   SURGERY.  21 

offending  muscles.  The  last  named  may,  often,  be  completely 
relieved  by  apparatus  and  appropriate  remedies.  An  ap- 
pliance which  shall  fix  the  head,  and  enable  us  to  act  upon 
it  steadily  and  firmly,  has  been  a  desideratum  in  surgery, 
not  only  for  the  treatment  of  the  complaint  we  are  now  con- 
sidering, but,  also,  when  dealing  with  the  deformities  arising 
as  a  sequence  of  burns  and  from  other  causes.  I  have 
seen  but  one  apparatus  that  does  this  effectually.  It  was 
invented  by  Dr.  John  B.  Brown,  some  years  since.  This 
instrument  answers  every  indication  in  torticollis,  and,  for 
accomplishing  the  object  desired,  is  nearly  perfect.  "We  have, 
in  this  affection,  to  contend,  first,  with  the  sideward  inclina- 
tion of  the  head,  which  sometimes  almost  touches  the 
shoulder ;  secondly,  with  the  rotation,  by  which  the  face  is 
turned  towards  the  opposite  shoulder;  thirdly,  with  the 
tendency  to  stoop,  or  posterior  curvature  of  the  dorsal 
vertebrae ;  and,  fourthly,  with  the  lateral  curvature,  which 
is  the  inevitable  result  of  the  disturbance  of  the  equi- 
librium above.  The  apparatus  referred  to,  consists  of 
a  padded  steel  belt,  which  firmly  grasps  the  pelvis. .  From 
the  centre,  opposite  the  sacrum,  arises  a  strong  steel 
upright,  terminating  in  a  steel  skull-cap,  which  encircles 
the  head,  with  a  tongue,  projecting  obliquely  downwards 
and  forwards,  to  press  upon  the  superior  and  inferior 
maxillary  bones.  There  is  a  crutch,  on  one  side,  to 
balance  the  instrument  and  to  support  the  depressed 
shoulder.  A  broad  belt,  also  of  steel,  attached  to  the  back 
upright,  embraces  the  body  below  the  axillae,  and  buckles  in 
front.  About  two  inches  below  the  cap,  upon  the  posterior 
standard  and  opposite  the  cervical  vertebrae,  is  a  circular 


22  CASES   m   ORTHOPEDIC  SUEGERY. 

ratchet-wheel  which  acts  in  such  a  way  as  to  rotate  the  head ; 
below  this,  another,  working  in  a  dififerent  direction,  tilts  the 
head  towards  either  shoulder.  A  third  ratchet-wheel,  oppo- 
site the  middle  dorsal  vertebrae,  acts  antero-posteriorly,  and 
corrects  the  stoop  which  is  a  frequent  accompaniment  of 
torticollis.  A  fourth  is  placed  near  the  insertion  of  the 
standard  to  the  pelvic  belt.  This  turns  from  side  to  side, 
and,  by  means  of  the  upper  belt,  below  the  shoulders,  un- 
bends the  lateral  curve  of  the  spine,  which,  as  has  been 
stated  above,  is  always  present  in  a  confirmed  case  of  wry 
neck. 

For  the  milder  varieties  of  this  affection,  where  less  power 
is  required,  I  have  contrived  a  less  complicated  but  very 
efficient  instrument.  This  is  a  double  spring  stock  to  sustain 
the  head,  from  which  two  pieces  of  steel,  about  a  foot  long 
and  half  an  inch  wide,  extend  down  each  side  of  the  spine 
and  are  secured  to  the  waist  by  a  leather  belt.  There  is  a 
check  for  the  chin,  and  a  spring  against  the  occiput,  by  which 
the  head  is  turned  and  retained  in  a  position  the  reverse  of 
that  towards  which  it  is  abnormally  inclined. 

Another  of  the  sequelae  of  torticollis  is  the  series  of  re- 
markable twists  which  gradually  occur  in  the  facial  linea- 
ments. The  physiognomy  becomes  characteristic.  The 
eyes,  nose,  mouth,  and  even  the  eye-brows,  endeavor  to  adapt 
themselves  to  the  one-sided  position  of  the  head.  There  is 
a  persistent,  involuntary  effort  made,  by  the  muscles,  to  com- 
pensate for  this  obliquity  and  to  restore  the  normal,  relative 
position  of  the  features.  This,  in  time,  produces  a  very 
peculiar  appearance  of  the  countenance,  which  is  pathogno- 
monic of  the  complaint. 


CASES  IN  ORTHOPEDIC  SUBGERY.  23 

Case  XX.    Photograplis  Nos.  1  and  2. 

The  last  case,  of  which  I  have  to  speak  this  morning,  is 
that  of  a  girl  twenty  years  of  age,  whose  situation  before 
treatment  is  shown  in  this  photograph.  (See  Case  XX., 
Plate  Vni.,  figure  1.)  When  eleven  years  old,  while  at 
play,  she  was  thrown  from  a  height  of  sixteen  feet,  by  the 
caving  in  of  an  embankment,  the  lumbar  and  sacral  spine 
striking  upon  a  large  stone.  The  fall  produced  insensi- 
bility for  a  few  moments.  She  then  recovered  and  went  to 
school.  She  continued  her  usual  avocations  for  five  or  six 
weeks,  growing,  daily,  more  and  more  feeble.  She  was  then 
attacked  with  agonizing  pain  in  the  lumbar  region,  followed 
by  complete  loss  of  sensation  and  motion  below  the  hips. 
The  thighs  and  legs  gradually  contracted,  until  the  left  knee 
was  forced  against,  and  under,  the  right  thigh,  and  the  thigh 
was  drawn  up  to  an  acute  angle  with  the  body,  and  twisted  to 
the  right.  These  parts  were  in  such  close  contact  that 
it  was  with  difficulty  I  forced  the  knee  from  under  the  thigh 
where  it  had  lain  for  years.  The  patient  had  extreme 
lateral  curvature,  with  excessive  incurvation  of  the  lumbar 
vertebrae.  The  first  photograph  was  taken  nine  years  after 
the  accident.  By  means  of  subcutaneous  division  of  ten- 
dons in  the  groins,  popliteal  regions  and  in  the  feet,  fol- 
lowed by  mechanical  appliances,  together  with  a  carefully 
adjusted  spinal  apparatus,  the  girl  was  in  three  months 
straightened  out  as  seen  in  the  second  representation.  (See 
Case  XX.,  Plate  VIII.,  figure  2.) 

There  are  other  photographs  and  models  upon  the  table, 
for  examination,  by  any  gentlemen  who  may  feel  interested. 


PLATES 


The  figures  in  the  accompanying  Plates  are  photo- 
graphic representations  of  most  of  the  cases  de- 
scribed in  the  preceding  paper.  They  are  copied 
with  an  accuracy  only  attainable  by  that  wonderful 
art  which  permits  the  subject  to  stamp  its  own 
image. 

Each  one  is  the  type  of  a  class,  or  is  illustrative 
of  practical  facts  referred  to  in  the  text,  and  is  in- 
dicated by  numerals  under  the  appropriate  heads. 


PLATE     I 


CASE  I. 

Fig.  1.    Before  treatment.  Fig.  2.    -After  treatment. 


CASE    II. 


Fig.  .3.    Left  foot  before  treatment. 
Fig.  5.   Right  foot  befure  treatment. 


Fl;.'.  4.    Left  foot  after  treatment. 
Fi(;.  6.    hight  foot  after  treatmeut. 


PLATE    II. 


CASE  III. 

Fig.  1.   Before  treatment.  Fig.  2.   -4  fler  treatment. 

CASE    IV. 
Fig.  3.   Before  treatment.  Fig.  4.    After  treatment. 

CASE   V. 
Fig.  5.   Before  treatment.  Fig.  6.   After  treatment. 


PLATE     III 


CASE  vr. 

Fig.  1.    ISefore  treatment.  Fig.  2.   .4fter  treatment. 

CASE  VII. 
Fii^.  3.   B'ljfore  treatment.  Fig.  4.    After  treatment. 

CASE  VIII. 
Fig.  5.    Before  treatment.  Fig.  6.   After  treatment. 


PLATE    lY 


CASE  IX, 
Fig.  1.   Before  treatment  Fig.  2.  After  treatment. 

CASE    X. 
Fig.  3.  Before  treatmenu  Fig.  4.   After  treatment. 


J.   J.    BA«tS, 


PLATE     V 


CASE  XI. 
Fig.  1.   Before  treatment.  Fig.  2.  Twelve  years  after  treatment. 

CASE    XII. 
B'ig.  3.   Before  treulment.  Fig.  4.   After  treatment. 


J.    i.    KAWI5, 


PLATE      VI 


CASE    XIII. 
Fig.  1.  Genu-valgun;  of  right  leg,  before  treatment. 
Genu-varura  of  left  leg  "  " 


Fig.  2.  After  treatment. 


PLATE      VII 


CASE    XVI. 
Lateral  Curvature  of  thb  Spine. 
Fig.  1.    Before  treatment.  Fig.  2.   After  treatment. 


PLATE     VIII 


CASE    XX. 
Distortion  of  the  Spisb  and  Limbs. 
Fig.  1.   Before  treatment.  Fig.  2.   After  treatment- 


405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

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ii 


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WE168 
B877e 
1868 
Brown,  Buckminster . 

Cases  of  orthopedic  surgery 

BlBTlOtheca  ^llUilln^M  Pnnniif 

WE168 
B877e 
1868 
Brown,  Buckminster. 

Cases  of  orthopedic  surgery 


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